bimalc

We no longer routinely provide abx prophylaxis in uncomplicated gastroschesis (your question is not really in my area of expertise, but this protocol was just reviewed so it is on the top of my mind)

Given that this has lasted a month, if infectious causes and basic metabolic screens are unrevealing, monogenic causes of cholestasis are likely, more so if there is consanguinity in this family.

If you're actually worried about extubation failure, there are evidence based things you can do to improve chances of successful extubation such as extubating to NIPPV and having the non-invasive interface setup (or even part way on the baby) at time of extubation to minimize loss of FRC. There is no evidence that I am aware of to support re-loading caffeine.

I have done this in our medical NICU patients who have become de-recruited for any number of reasons, but not routinely on preemies (I mostly work in an outborn NICU that, in many ways, sees pathology closer to a pediatric ICU just in neonates who may incidentally be premature and are often coming to us at or new term corrected or later). No protocol, just recognition that this is an issue and taking the fellow and RRT to bedside and performing a series of recruitment maneuvers either with vent or by hand bagging.

no and no

So I think there are two issues here: 1) Why do you think the child is anuric and what mode of kidney support therapy are you proposing to address the issue? (as an ancillary - what is the end point?) 2) Given the size, is your proposed plan even technically feasible? Assuming you mean PD and not CRRT/iHD, https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-020-02092-1 provides some experience and suggests that it may at least be technically feasible. Beyond that, I think you'd need to provide more details on the actual circumstances that led you to want to pursue PD for anyone to sensibly answer your question.

We have a pharmacist enforced hard stop at 24h on all antibiotics and stewardship review of anything longer than 48h

'Use' in what sense? We record all of that data and I am sure it goes into our research databases, but we've not made any major changes in our threshold for consulting our BPD service since the paper came out (basically anyone still on CPAP at 36 weeks gets a BPD consult, some neonatologist variability on when to call for the kid on a low flow NC who is marginal).

I will assume for a moment that you refer to 22/23 week neonates weighing <500g as I would argue that a 28 weeker can easily be secured with either a Miller 0 or a 00 blade which have been available as long as I have been in practice. More recently our hospital began demo-ing a variety of new laryngoscope blades and I got to try out a miller 000 blade from intubrite that, to me, looked comically small, but was surprisingly effective in our micro preemie manakin. Which is to say I'm not sure there's much of a shortage of equipment for DL. I have NOT seen good VL equipment for the 22/23 week population. On this I would agree and would welcome input from anyone who is aware of VL equipment for this size patient.

The point about the VL is an important one. If intubation becomes a high risk/low frequency event, we should take a safety perspective and engineer our systems for safety, not widespread procedural competency with direct laryngoscopy. I am a physician-scientist who primary covers a level IV NICU without a delivery service. The over all number of intubations is relatively low and in most emergency circumstances there is a front line provider (typically NNP), a (very) experienced charge NNP, and a neonatal fellow available for managing the airway while I run the code. I can now count on one hand the number of times per year I even pick up a laryngoscope outside of a simulation (and as often as not, given that several experienced providers have tried to intubate before me, I'm busy re-engineering the situation to improve success or avoid need for intubation rather than somehow getting the tube in when others could not). I am confident that I've probably reached the point where I am significantly safer/better with VL than DL. This isn't just about trainees any more.

Same as you, for the most part. Keys in my view are: 1) Anticipation of risk factors (length of intubation, cuffed tube, lack of leak, parenchymal lung disease which may make the child more prone to struggle with even transient upper airway narrowing, etc) 2) Early recognition/treatment with nebulized Epi and Steroids as well as consideration of heliox as a further temporizing measure until steroids can kick in 3) Shared mental model with frontline staff that re-intubation may be more challenging and/or need to happen fairly expeditiously if the airway cannot be preserved non-invasively

In my units, provider preference, though as far as I am aware we all invite families to remain with the baby. Assuming it is a controlled intubation, I do warn parents that they cannot get in the way of staff and so should remain off to the side, preferably seated, just in case they become faint or ill watching the intubation and I emphasize to them that all our attention will be on the baby and if they think they will become a distraction to the team that they may want to go for a walk or sit in the waiting room instead. I would say 75-80% of families say they'll step out and wait for us to get them, the rest choose to stay. It has never particularly bothered me, but I've had parents watch me perform intubation since I was an intern so it is all I've ever known.

Honestly, I do so little service at our delivery hospital now that I cannot recall the last positive I cared for. If you are interested, email Pablo.sanchez@nationwidechildrens.org as he is very active in CMV research.

As @rehman_naveedsaid, this is NOT excess sodium provision. The baby is total body water depleted from all the ways an ELBW can lose free water (mostly skin and urine). You minimize insensible water losses (plastic bag, double wall isolate if available, etc) and, if these measure are not sufficient, provide more free water by increasing your total fluids. Without knowing the details of your fluid management, it is difficult to say more, but from your question, this is almost certainly the problem. What day of life are you seeing this issue? How much weight loss are you seeing (a marker of water losses early in life)? What is your current fluid management?

We screen all neonates on admission

It is a scandal that this is even still a debate. To suggest we should routinely intubate without NMB is about as evidence based as suggesting neonates don't feel pain.

Can you provide more context on the patient population/circumstances you are interested in? I doubt there are general guidelines given the wide array of underlying etiologies which might lead to hypoglycemia. In general, my approach includes assessment of the reason for the original hypoglycemia, current degree of enteral tolerance/expected tolerance, present glucose levels, risk of critical hypoglycemia with weaning of GIR. At a high-level, though, I view the IV glucose as ensuring metabolic stability while enteral nutrition established. Depending on the urgency of coming off IVF we will wean GIR for pre-prandial blood sugars >60-70mg/dL.

In terms of BPD prevention we are incredibly aggressive about trial of extubation early in life with a culture that does not view early extubation 'failure' as failure; rather we celebrate everyday that these babies spend without an ET tube. For those babies that do go on to develop severe BPD, we have a dedicated BPD-ICU providing developmentally appropriate care by a neonatologist led team of medical providers, nurses and therapist specifically practicing in this patient population. That unit will keep kids admitted for months or even years if needed and extubate to high levels of non-invasive support as part of a pathway home without tracheostomy. Rates of tracheostomy are very low. Feel free to message me with your contact details and I can put you in touch with our small baby or BPD teams if you'd like. (I actually don't attend on either team; I primarily attend on our medical ICU team)

I'm assuming you mean PREMILOC dosing? My units do not use it officially because our BPD program is so good and also because of questions about magnitude of effect on NDI long term, but my deep suspicion is that, in most parts of the US, the hesitancy is driven by fear of legal liability in light of the Canadian and American Academy of Pediatrics positions recommending against routine use of post-natal steroids. Overall, I think the published evidence is sufficient to support but not mandate a change in practice, but no one in the AAP asks my opinion.

I am not aware of such a case, but I must ask what led you test for both conditions?

As a practical matter, it is unlikely because the volumes are so small that when dissolved in feeds over the course of the day their impact is negligible

This is so important, not just for development for for the water loss. People think isolettes are magic, but every time we open them we cause water loss.

If you are asking about enteral supplementation for the 'normal' hyponatremia that ELBWs get after the initial diuresis is complete, our goal is to correct this over a week, though often it takes us 2 weeks to get it right. We follow electrolytes and increase dosing every 2-3 days, paying at least as much attention to the chloride as the Na (we occasionally need to do a mix of NaCl and NaHCO3)

You can, in the sense that it is physically possible, however this is likely not advisable as the volumes involved are too large. 0.9% NaCl is 154mEq/L. 1mEq Na = 1mmol. 1mmol Na/kg = ~6.5mL/kg. Over the course of a day 4mmol/kg/d is ~25mL/kg/d. By way of comparison, our local liquid NaCl preparation is 2.5mEq/mL so 4mmol/kg/d is <2mL/kg/d. My advice is that if NaCl tablets are not available in your country but you have a pharmacy capable, see if you can source NaCl powder. 146g NaCl plus QS sterile water to 1000mL final volume will give you a bulk solution of the appropriate concentration. Alternatively (and I have never done this, nor am I aware of anyone who has done this safely) 3% and 5% IV NaCl solutions are often stocked for use in neurosurgical patients. The required volume would be a more reasonable ~8mL/kg/d or 5mL/kg/d with either of those solutions.

No electrolytes (except possible Ca) in the first day or so, introduce modest amounts of Na and K in IVF/PN on day 2 or 3 based on diuresis and serum Na level. Closer monitoring is required in ELBW/EPT infants. In my experience in the early going the biggest problem people get into is giving too much free water as opposed to being off on the amount or timing of Na administration. After a couple of days the biggest problem, especially in ELBWs, is that massive amounts of acetate given in TPN to compensate for the normal RTA are not adjusted quickly enough and people overshoot and end up with iatrogenic metabolic alkalosis. Later we see the problem of inadequate provision of NaCl manifesting often as poor weight gain (especially in the ELBW advanced on term donor milk).